Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Friday, September 14, 2007

So my post from a few days ago-- Are You My Patient? -- inspired a lot of thought-provoking ideas, and thanks to everyone for the comments. I wrote about patients who come to treatment, and then reject all suggestions, thereby leaving the doc feeling a bit helpless.

To be honest here, I've really only felt held-hostage by this situation a couple of times-- most people who don't like my ideas simply stop coming. And the very few times I've actually pointed out to a patient "Look, you're suffering and then you won't do anything I suggest, you won't even try the medications I recommend....yadayadayada..." Well, once I've confronted them, for the most part, they've made an effort.

Gerbil wrote in with a comment that really got me thinking. She said...

May I also point out Prochaska's stages of change model? It's a common misconception that people go directly from one stage to the next, from precontemplation through maintenance. More often, it's not linear at all--they flit back and forth among the stages.So it's entirely possible that someone would decide "hey, it's time to get help," but by they time they actually make it to the office, they're back in denial that they even need the help in the first place.And besides, isn't resistance the best therapy fodder there is?

So who's this Prochaska character and what Stages of Change?-- Follow the links, I looked it up and I was pleased that a reader made me learn something new.

But this is the thing: given that my post was about patient compliance, it really wasn't about compliance with Psychotherapy, it was more about compliance with medications and behavioral suggestions. Until Gerbil chimed in, I really wasn't thinking at all about compliance with psychotherapy or resistance.

There is an obvious way a patient can be non-compliant with psychotherapy: They can simply not show up. But let's push that one aside-- and let's just say the patient shows up on time. Is it possible, then, to be non-compliant with psychotherapy, in essence, to not talk about the rightt hings? I presented my Are You My Patient? post with an edge of frustration. Is it reasonable for the therapist to get frustrated with a patient because the patient doesn't talk about the right stuff?

In a traditional psychodynamic psychotherapy patients are urged to dig deeper, to talk without censoring, to explore and breakdown defenses, to travel down that royal road to the unconscience and resolve all those conflicts while unrepressing the long-ago repressed. The treatment of trauma-related disorders often calls for the patient to talk about difficult things that have happened in the past. Clearly, there are right and wrong things to talk about?

Maybe there are things that should or shouldn't be said in psychotherapy. I rambled last year about What Patients Talk About In Psychotherapy (-- at least check out the cartoon!) and I tried to make the point that people often talk about mundane things. I would contend that it's pretty hard for patients to talk about the Wrong things in psychotherapy. Patients generally come and talk about whatever is important to them, and they usually find this helpful, even if it's not anything terribly difficult, shameful, or all too deeply hidden in their psyches. Some patients talk in very introspective and insightful ways about pretty powerful things, and then say it's no big deal, it isn't particularly helpful, and while they seem to be doing great work, nothing changes. Other patients talk about things they could easily share with a friend-- nothing all that personal or earth-shattering, and relate that it's extremely helpful and they get a lot of relief. If a patient says there's something they don't want to talk about, well...I might push a little, but mostly I respect this-- it can be addressed later or not at all. Psychotherapy, even if difficult at times, should ultimately offer relief and shouldn't be about badgering or belittling the patient. Oh, and the other thing: the relationship itself is much of what helps, and this relationship happens (in good or bad ways) regardless of what is said.

As a patient I've occasionally wondered about this and, perhaps surprisingly, this crosses over into my experiences as an art student and art teacher in class critiques.

I can't recall any of my professors use the words "right" or "wrong" or "good" or "bad." Instead it's always been something like "successful" and "unsuccessful."

As I reason it in my own head, words like "right" and "wrong" imply polarized thinking. Yes/No. On/Off. Black/White. One/Zero. A lot of us often simplify things this way, likely because it's easier. The reality is, of course, a spectrum between the two extremes.

In a class critique, instead of saying a student's photograph is bad I put in an effort to find both "unsuccessful" and "successful." There's something of merit in every photograph. Otherwise, why would the student have made it in the first place?

To get back on track here, I can't believe that a patient could say anything wrong in therapy. It could be wildly off topic and it could be very unproductive but isn't it possible that there's still something to it? Some tell or some loose thread just waiting to be pulled?

All that being said, I totally understand the frustration and anger. In a group therapy session I was a part of a while back, a new member spent almost the entire hour-and-a-half discussing the placement of the clock in the room. Terribly unproductive.

Gerbil, I do a lot of addictions work, so I speak stages of change (though, Proboscis or whatever doesn't flow so easily). But I never heard about any of this in training (late 80s/early 90s). But, we do indeed get lighter version, I suspect, of broad areas of psychotherapy models, but with deeper education and training around specific models (eg, CBT, IPT, DBT, supportive, psychodynamic).

Jon, of course, you are right (umm, successful). I think Dinah is using shorthand. I think when she says "the right things" she actually means "the things I think would be helpful to address."

A creative therapist (which she is) has the skill to turn any unproductive line of discourse into a productive one, and can do so smoothly and gently, yet persistently. And then address the resistance when it becomes obvious.

Gerbil, I believe you are right that psychiatrists don't learn as much about theories of a lot of things, psychotherapy included. I was an undergrad psych major and there were many things I learned as an undergrad that were never mentioned in shrink-training.

Jon S.-- yes I think "successful" vs "unsuccessful" is a better, and perhaps gentler, way of distinguishing. And as in Art, where one person's Wonderful is another person's Garbage, there is a degree of subjective opinion and unpredictability about what makes psychotherapy work. Thanks for chiming in.

And Roy-- I meant "the right things" without a short cut. I believe there is a whole judgemental aspect to some views of psychotherapy and what the practioner believes the patient should be talking about-- such that the therapist has the option to blame the patient for being introspective enough and for not being a good therapy candidate--he's wasting the sessions, avoiding the issues, keeping it on the surface, refusing to talk about the harder stuff-- and yet some people talk about very surface stuff---eg how to hang a clock on the wall-- and end the session saying they feel much better, the therapy is helpful, their symptoms abate, they value the relationship. Really, so much of it's about the relationship.

To say that anything can be "talked about" is not to say that any matter, at face value, can be specifically addressed. The very stereotype of talk therapy is that there's no testimony so dire or bizarre or wracked that therapist can't respond to with a mere "Umhm" or "And why do you think that is?"

For Jon-- I borrowed your example, I meant to add that it's unfortunate if this sort of thing hijacks a group and prevents the other members from getting help...Anyone who talks about clocks for that period of time should be in individual treatment

I'm wondering if you remember my blog post that commented on your "what patients talk about" post that I think may have lead you to even expand further on that initial post. If so, it will come at little or no surprise to you to learn that "talking about the right thing" comes up a lot in my therapy. Now the last few weeks, I've been working harder to jump right into the "harder" stuff and skip over the "filler material" (which is really also important, but more day to day), but before, I always started with random day to day stuff that wasn't really at the heart of the problems.

Sometimes, after I'd finish talking about something, he either wouldn't comment or somehow lead it into the hard stuff, and I'd get the impression that I wasn't talking about the "right" stuff. Or at least, that's what I thought he was indicating. Then, one time, he interrupted my monologue on several things on my mind, and he said something along the lines of "When you decided to talk about these things, what did you hope to get out of it" or "why choose these things to talk about" or something like that...which subsequently caused me to burst into tears. I (over)reacted very strongly, thinking he was implying that what I was saying was not important. He later asked if I thought he was being insensitive. I don't like to admit anger - it's easier for me to turn things into inward self-hate and depression than it is for me to be angry at someone else. So it led to an interesting discussion. (Which was something like pulling teeth...)

So in the end, I find that I often have this concept that he thinks there are "right" and "wrong" (or, less important) things to talk about in the session. However, it often is not that. It's not that he necessarily views what I'm talking about as "wrong", but perhaps in the scheme of things less important (I'm speculating) but only in a way that indicates that there are deeper, more difficult things that are MORE important to talk about. So it's not that what I'm saying is less important, but just that something else is more important than that. (Say that 10 times fast...)

At any rate, "talking about the right things" is a frequent fear and stress of mine. Sometimes when I'm driving there in the car (now my 45 min to 1 hour drive to appts twice a week), I start thinking in my head what I'm going to talk about - sometimes even the night before or even days before. I think my anxiety comes from the fact that the session always takes on a life of its own that I could not have prepared for....it doesn't fit the predictable pattern that I cling to so closely in the rest of my life for comfort. Still trying to figure out why I get so nervous in my appts.

Today I experienced something that is both a day-to-day type issue (since it occurred today) but will also fit with an overarching theme of discussing interpersonal relationships. So, whenever something like that happens, I wish I had an appt tomorrow instead of Tuesday... hehe

Dinah said... ...Anyone who talks about clocks for that period of time should be in individual treatment

Heheh

That was an especially bad quarter of group. (My school runs on the quarter system and thus group therapy can only last 8 or 9 weeks because everyone's schedules change. It's an awful way to run a group.)

He did, in a sense, hijack the group that session, but others played along with it. It's way easier to talk about why the clock isn't on the wall and etc. than it is to talk about what's really going on with ourselves and we followed him down that road willingly.

I did cut in and said some very angry things near the end of the session but this only made the remaining weeks of that quarter's group awful as one of the co-facilitators kept bringing it up to try to force us to hash it out.

Anyways, having tried quite a few therapists myself, I agree with Dinah that "so much of it is about the relationship." I'm certainly more evasive during a session if I'm at all uneasy with the person in front of me.

I'm interested in how you guys perceive or deal with this chemistry (or lack of) with your patients. Through my experience I've never met a therapist who brought up the issue, whether to suggest that we might be better off seeing other people or even just to suggest that this relationship is important. (So I had to learn this lesson the hard way.)

But is this something you would eventually bring up to a patient? Or is this something the patient has to arrive at on his/her own?

Carrie, I think you raised a very interesting point - one that I'm just now starting to understand. The issue of "day-to-day" (or as I call it, "nuts and bolts") stuff that comes up generally makes up the material for my therapy. It's easy to regurgitate and generally doesn't hold the same emotional significance as much of the deeper rooted stuff that should be talked about.

Your therapist's response is interesting, and one that I wish I had in my head... Why do I say what I say? On one hand, shouldn't i be able to have the words flow freely from my mouth without having to filter my thoughts? On the other hand, shouldn't i be able to filter out the BS that keeps me from getting at the true issues that brings me to therapy...

I never fear that I'm talking about the wrong things. It's my time, and my money. I'm paying for my providers to listen, provide feedback and ultimately show me where and how to correct my thought patterns and processes. That being said, I think i could be using my time more wisely - but therapy isn't the only setting in my life that I feel this way.

He only ever said that the one time....and I don't think he meant it the way I took it, but I'm not sure!! He is very much an advocate for my speaking uncensored. However, I don't do that - really ever - about deep, emotional things. I can do that just fine about day to day issues. I really don't believe he thinks there are right or wrong things to talk about, but rather, that is what I often worry he is thinking.

Part of my problem is that I worry far too much about what other people think. We even recently changed the way we are doing therapy so that I'm not looking at him directly. This is just the past 2 sessions. Right now, it's making me very anxious, but I asked him why we were doing it, and he said it's kind of reminiscent of lying on the couch. You can't see the therapist's face, so that removes on element. I won't be attempting to read his facial expressions and make something up that's not really there. However, I mentioned to him last time that he never had a lot of facial expressions to read in the first place. I do get anxious when I feel his focus on me so strongly, and I often say that I feel "on the spot" and things like that, so this seating arrangement can kind of help with that. I could, if I wanted to, pretend he's not looking at me at all. We'll see!

Honestly, my own anxiety is what gets in my way. If I could speak uncensored, then I feel like I would get farther, but I get so anxious that it feels like I can't get words out a lot of the time. Funny how I can give hour + long piano recitals in front of tons of people, but yet I get nervous talking to people even 1:1 in person.

It all comes down to this concept that I worry far too much what other people are thinking. And it is me who makes up the fear of whether what I'm talking about is right or wrong. I still think he might encourage me to talk more often about the deeper, more root issues, but I don't think he would discourage me from talking about day to day things either!

Carrie-- absolutely I remember and I knew you'd have a comment to add here-- thanks.

Jon-- complicated question. For the most part, I think people deal with the relationship with their feet-- if they don't like the therapist, if they don't feel understood, if there's a lot of struggle, patients just don't schedule the next appointment (or they cancel and never call back, or they NO Show and are off to the sunset). And people who feel that either the talking or relationship are helpful often just volunteer this in subtle or not so subtle ways. Sometimes it needs to be addressed, mostly it happens naturally.

I believe that in any therapy, even conventional 5X a week on the couch psychotherapy (and I could be wrong here, I don't do this, but hey, I go to the movies too), much of what goes on is talking about what has happened since the last session. My mom made me feel badly when I was 7, probably should rank somewhere after I had a huge disagreement with my boss and I'm afraid I'll be fired-- in any therapy. I, too, would agree that one shouldn't spend a session discussing where the clock should hang in the face of impending job loss.

Some people feel some pressure to relate the events since the past session in a slightly pressured-hard to interrupt way, filled with lots of details, sometimes of things that don't seem to be of much consequence. It's how they want to do it, and the telling of the tale appears to be very important. Is it a defense against talking about deeper (whatever that means) things? I've come to assume that there's something important to those people about my knowing and understanding the details of their lives and they find it helpful to deposit (if that's the right word) this information with me.

I may want to repost a story I told last year about the patient who didn't talk.

Now I have to refill coffee and show Roy's post on Chloe to non-shrink family members

When I was doing therapy, I didn't talk so much about the things that happened between sessions, so much as the things I thought about between sessions, and about the emotions I felt about those thoughts. Or about things that did happen which had an impact on prior discussions about my thoughts and feelings. (Now I've got my patient hat on. We all have many hats.)

This post has really developed into a very interesting discussion for me. There are two elements of therapy that I spend a lot of time thinking about. No not clocks, not until now.

First, like Roy said, I tend to reflect between sessions and dig deeper, through writing, what I learned about myself during each session. I usually start the next session talking about these discoveries.

The second is eye contact. My therapist suggested that I speak to and make eye contact with men as I go through my days. The mumbling of a quick "Hello" was easy, but making eye contact was painful. I can't do it. Not only with men, but with everyone. Even my brother and my daughter. This "problem" is so profound that it is the name of my blog.

When I wrote about this I decided I want to talk to my therapist about it. The funny thing is I have no problem making eye contact with her. I didn't realize this until I read Carrie's comments that "the couch" was designed to help the patient avoid eye contact.

Turns out that it is a huge trust issue for me and apparently I have allowed myself to trust this therapist. So far, she seems to let me set the topic of discussion although she does keep me focused. Near the end of the last session after the discussion took a turn, she made a statement about what we need to be working on. So now that is the subject of my writings and musings leading into our next session. I didn't realize this until now. But I think that she is actually deciding what we'll talk about during the next session by making these subtle and not so subtle statements. Maybe I'm wrong.

...another thought: I am a veteran and a patient of the VA mental health program. I have had three sessions with this PTSD/MST specialist after floundering with a few others with whom I could not make eye contact. Nor could I talk of anything meaningful or stay focused. Back then, I kind of did the clock on the wall the thing. I guess it was simply an avoidance technique for me. One of those doctors added schizotypal tendencies to my diagnosis. Now I am thinking about that, wondering if it is a mistake.

Sorry for rambling.

Carrie, Rach, Dinah and Roy - thanks for your comments, The discussions help me understand the process of therapy.

I remember reading someplace (probably in some musty journal article from grad school) that there's sort of a wave-like pattern in the topics that people discuss in therapy sessions. As I recall, the gist of it was that if last week's session was very emotionally laden, then this week's session is likely to be less deep. It sounds pretty self-protective, and not necessarily in a "bad" way.

I guess if you declare in the first session that you're there to work on really deep, heavy stuff, but you spend the next several months talking about how your bagel order got screwed up again, it's in the best interest of the therapy for the therapist to point out (perhaps gently) that you're avoiding something.

Of course, this can backfire. I've had a few clients with anger problems who successfully avoided addressing the presenting problem directly for several weeks, but when I tried to guide us back to the anger, they got pissed off and dropped out of therapy.

Overall, the very idea of avoidance (and resistance, for that matter) assumes that the therapist knows which way the therapy must go, but the client is in the dark. Sure, the role of the therapist is to provide at least some guidance for the sessions; and maybe the client doesn't always know the best way to go; but in essence this concept removes all the power from the client and grants it all to the therapist.

Yes, analysis of the resistance (Freudian or not) does make for interesting and potentially helpful discussion. But I don't think a therapist can simultaneously do the unconditional positive regard thing and declare that the client is not talking about the "right" stuff. And therein lies the paradox.

Gerbil said... I remember reading someplace (probably in some musty journal article from grad school) that there's sort of a wave-like pattern in the topics that people discuss in therapy sessions. As I recall, the gist of it was that if last week's session was very emotionally laden, then this week's session is likely to be less deep.

Dinah said..."Some people feel some pressure to relate the events since the past session in a slightly pressured-hard to interrupt way, filled with lots of details, sometimes of things that don't seem to be of much consequence. It's how they want to do it, and the telling of the tale appears to be very important. Is it a defense against talking about deeper (whatever that means) things? I've come to assume that there's something important to those people about my knowing and understanding the details of their lives and they find it helpful to deposit (if that's the right word) this information with me."

Yes...yes!! That's exactly how my sessions were almost always starting until maybe 5 or 6 times ago. Right after he said the whole, "why are you telling me these things" comment...that's when I changed what I say at the start.

So, since you described what I was doing absolutely perfectly (down to the pressurized, don't even take a breath, absolutely every minute detail must be included way I was talking), I feel I can comment on why I do it! Part of it is defensive....but not just defensive against talking about deeper issues (although I find this is also the case). One way it is defensive is because I have such anxiety about the appt in the first place. As I said above, sometimes I spend days in advance thinking about what I'm going to start the appt with. I can't just go in and sit there and wait for something to happen - that would KILL me - it's like my worst fear to just sit there in absolute silence. So I have to have something prepared to talk about so that doesn't happen.

And then there's more to it than that. You're right in that it is the telling of the tale - way more than the tale itself. For me, this is important for at least one major reason. I am, consciously or unconsciously, testing if you are listening. (Well, not you personally...) This fast-paced, pressurized speech comes from a history of being told I talk too much and being cut off and not listened to. I want to tell the stories I am telling - but I say them in such a pressurized way because I want to get it out before you even have the chance to tell me to shut up, like what I know so well. If I stop to take a breath, then that might happen, so I best not even stop.

My other fear is that if I stop, he will say nothing and we will sit there in silence, with my rambling words hanging in the dead space. This is also unnerving to me. It makes me incredibly self-conscious and a lot of what I feel in those moments is instant self-hate for talking too much. I cannot stand to share a story in great detail and then finally stop talking after several solid minutes and have him not say anything. That makes me feel like absolute crap....honestly.

And there's something else. There's something to the fact that I have to share every story in my life in such detail. Hey, when I ran into problems at my job wayyyyy back on orientation, it was because my time management was terrible. I personally feel this was because I couldnt' get focused - I could not differentiate between big details and little details.....everything was "most important". This is what happens in my stories. I can't cut something out or it feels like I didn't tell it right. (NOW we know why everything I write is so darn long and rambly...) I am completely unable to differentiate between the important points, and the details I should just leave out. I have to tell it all. It really causes me internal distress when I tell a story and I leave out a single detail. Often, that makes me go back and include the detail and then keep going. So a lot of my phone conversations with friends and family end with them completely not even listening to me at all, paying attention to something else instead of our conversation, or saying they have to go before I even finish the story. This is unbelievably frustrating to me, but I feel I cannot change. It drives me up the wall if I do not include every detail. In the same way as not checking the front door lock every single time I walk past it also drives me up the wall.....I just cannot stand not to check it. If I walk past the door and go into my room without checking the lock, then I have to go out of my room to check it again. That's what it is like if I leave out details. (And before someone pegs me as a complete narcissist (sp?), I must say - I also listen better than most people I know. People say you can't talk and listen, but this is just not true. My mind just goes 100mph 24/7 - I really enjoy listening to people, and I listen very intently and very seriously - I don't spend all my time talking without letting the other person get a word in!)

So that's some of why I tell my day-to-day stories in the way you so perfectly described!!

I mentioned above that yesterday I had an experience that counts as both day to day and as something deeper. This was perpetuated today by every single time I talked to Jason (my boyfriend), him saying to me, "Did you get in any fights yet today?" or "Trouble Maker" and other such things. I really hope, on Tuesday, I can gain some insight on how to better handle interpersonal confrontations that I did not start. I think that's a good goal, and a good way to incorporate day to day experience with something deeper. You can bet that I'll once again tell him the story without so much as taking a breath! haha... Some things never change... ;)

When I sometimes go on about stuff in minute detail, or irrelevant detail, or the whole thing is . . . well anyway, for me, it's because the filter isn't there.

It's like the iron gates under the castle wall in the moat that keep people from swimming up it, or whatever. The blacksmith who made me connected the bars too far apart.

Or it's like lowering the castle iron gate w/the pointy things on the bottom, but the winch is busted and will only lower it 2/3.

I, too, from my earliest memories, well, those that are . . . well, that there are words, context related to, remember being told to shut up, and that I talked too much.

I don't think people realize how this can damage a child. People need to learn gentler ways of helping talkative children.

Anyway, for me there is some of the, I can't not include all this detail, Ie, I HAVE to include everything I include . . . but alot of it is like a fishing net that was tied w/holes too big . . . . I've been told to filter, my whole life, and it's like a confused puppy that doesn't know what to do when you say, go read me some shakespeare.

To Carrie and Sarebear and even to the patient out there who probably doesn't know from Shrink Rap but likes to talk about the correct place to hang a clock: I talk too much too (not quite as much as that verbose little ClinkShrink). Fortunately, I believe I have other redeeming qualities and there are many worse things than being talkative. It's good that the world is full of Roys to guide us back to the topic at hand!